New Patient Registration Form

Thank you for visiting our office.  We want your visit to be pleasant and comfortable. Please help us by completing this form.

All of this information is completely confidential.

Patient Information

Full Name (Last, First, Initial):  
Preferred Name:
Address:
City State, Zip: ,
   
Phones: Home-    Work-    Cell-
E-mail Address:
Soc Sec #(if you do not have social security please enter all zeros)
Sex:
Male Female
Date of Birth:
Marital Status:
Single Married Widowed Separated Divorced
Patient Employer/Occupation:
Emergency Contact:
Spouse's Name:
Spouse's Employer/Occupation:
Where you did you hear about our office?
(Check all that apply)
Friend/Family/Person
Google
Mailer
Event
Dental Savings Plan
Dentistry from the Heart
Facebook Commercial
Facebook/Social Media
Insurance
Radio
Real Life Smiles
Saw our Sign
Schiffert Health Center (VT)
TV Commercial
Another office

 

Responsible Party Information

Note: Subscriber who holds insurance/Person Financially Responsible may be a parent, spouse or partner, grandparent, etc.
 
Contact same as above
 
Person Financially Responsible:
Relation to patient:
   
Address:
City State, Zip: ,
   
Phones: Home-    Work-
Employer:
Soc Sec #(if you do not have social security please enter all zeros)
Date of Birth:


Dental Insurance Information

Is patient covered by dental insurance?
Yes No
(If yes, please complete the following:)  
Policy Holder Name:
Relation to Patient:
Address:
City State, Zip: ,
Phones: Home-    Work-
Soc Sec #(if you do not have social security please enter all zeros)
Date of Birth:
Upload Image Front of Dental Insurance Card:
Upload Image Back of Dental Insurance Card:
 OR 
Insurance Company Name:
Insurance Company Phone:
Group #:
Subscriber ID#:
   
Is patient covered by additional dental insurance?
Yes No
(If yes, please complete the following:)  
   
Policy Holder Name:
Relation to Patient:
Address:
City State, Zip: ,
Phones: Home-    Work-
Employer:
Soc Sec #(if you do not have social security please enter all zeros)
Date of Birth:
Insurance Company Name:
Insurance Company Phone:
Group #:
Subscriber ID#:

INSURANCE AUTHORIZATION & FINANCIAL RESPONSIBILITY AGREEMENT

I understand that I am financially responsible for all charges whether or not paid by insurance. I assign all insurance benefits directly to the doctor otherwise payable to me for services rendered. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
     
Signature (Parent/Guardian if under age 18) Relationship (if patient is under age 18) Date

Medical History

Patient Name:
Physician's Name:
Phone:
Date of Last Visit:
Please check the box if you have ever had any of the following:
AIDS or HIV positive Acid Reflux/ G.E.R.D Arthritis, (Supply Type in Details Below)
Artificial joints Asthma Cancer
Chemical Dependency Dental Anxiety Diabetes, (Supply Type in Details Below)
Eating disorder Epilepsy Excessive bleeding
Glaucoma Hepatitis, (Supply Type in Details Below) Kidney problems
Liver problems or Jaundice Lung or breathing problems Sinus trouble
Smoking/chewing tobacco Stroke Swollen neck glands
Thyroid problems Tuberculosis None Of Above
Heart Problems: Allergies: Women:
Artificial valves
Congential heart defects
Heart Surgeries
High blood pressure
Infective (Bacterial) Endocarditis
Low blood pressure
Other (Supply details below)
Pacemaker
None Of Above

Antibiotics for dental treatment
Currently under a physician's care
Serious illnesses/hospitalizations
None Of Above
Aspirin
Codeine
Latex
Local anesthetic
Penicillin
Sulfa
None Of Above

Other Allergies: 
Are you pregnant? 
No
Yes

Due when? 
Are you nursing? 
No
Yes
Medications: Please list medications you are currently taking and why
 

Dental History (New Patients Only)

Checkmark if you have ever had any of the following:
Bad breath problem Biteguard / Nightguard Canker sores in mouth
Cold sores on outer lips Dental anesthetic problems Excessive gag reflex
Fear of dental care Frequent headaches, neck aches Full dentures / Partial dentures
Gum disease treatment Oral surgery Orthodontics (braces)
TMJ, jaw joint pain or treatment None Of Above
Checkmark if you currently have any of the following:
Bleeding gums Broken tooth or filling Clenching or grinding of teeth
Clicking or popping jaw Dry mouth Food packing between teeth
Loose tooth Mouth breathing Pain
Pain around ear Sensitivity to - heat - cold - biting Sensitivity to - sweets - pressure
Sores or growths in mouth Swelling Tired, sore or painful jaw joint
Toothache Vague ache None Of Above
Other:
Give details and location of the above checked items:
   
How often do you brush?
How often do you floss?
What type toothbrush do you use?
Ultrsoft Soft Medium Hard Electric
   
Reason for today's visit
Former Dentist , City/State:    Phone:
Date and reason of last dental visit:
Date of last dental X-rays:
   
What have you liked about any dental office you've been to?
What have you liked LEAST about any dental office you've been to?

TREATMENT AUTHORIZATION

Is there anyone that you would like us to be able to release these forms to with your consent?
Name   Phone  

I have reviewed the information on this form and it is accurate to the best of my knowledge. I authorize and give consent for the dentist and/or team of this office to perform dental services as agreed between doctor and patient and/or guardian, including the use of local anesthetic and other medication as indicated.

     
Signature (Parent/Guardian if under age 18) Relationship (if patient is under age 18) Date

 

- NOTICE OF PRIVACY PRACTICES -

This notice describes how health information about you may be used and disclosed,and how you can get access to this information.Please review this notice carefully. Your privacy is important to us.

OUR LEGAL DUTY


We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 3/8/2010 andwill remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain;including health information we created or received prior tothe changes. Before we make a significant change in our privacy practices, we will change this Notice and provide the new Notice at our practice location.We will also distribute it upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices or additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION


We use and disclose health information about you without authorization for the following purposes:

  • Treatment: We may use or disclose your health information for your treatment. For example, we may disclose your health information to a physician or other healthcare provider providing treatment to you.
  • Payment: We may use and disclose your health information in connection with our healthcare operations. For example, quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing services.

PATIENT RIGHTS


  • Access: You have the right to look at,or get copies of,your health information with limited exceptions. You may request that we provide copies in a format other than photocopies. We will usethe format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may make such arequestby using the contact information listed at the end of this Noticetosend us a letterorobtain anaccess form.
  • Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
  • Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. In most cases, we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in certain circumstances where disclosure is required or permitted, such as an emergency, for public health activities, or when disclosure is required by law). We must comply with a request to restrict the disclosure of protected health information to a health plan for purposes of carrying out payment of health care operations (as defined by HIPAA) ifthe protected health information pertains solely to a health care item or service for which we have been paid outof pocket in full.
  • Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or at alternative locations (you must make your request in writing). Your request must specify the alternative means or location and provide satisfactory explanation of how payments will be handled under the alternative means or location you request.
  • Amendment: You have the right to request that we amend your health information. Your request must be in writing and it must explain why the information should be amended. We may deny your request under certain circumstances.
  • Electronic Notice: You may receive a paper copy of this Notice upon request, even if you agreed to receive this Notice electronically on our website or by e-mail.

  • To Your or Your Personal Representative: We must disclose your health information to notify or assist in the notification (including identifying or locating) of a family member, your personal representative, or another person responsible for your care, to inform them of your location, your general condition, or death. If you are present, then prior to the disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your absence, incapacity,or in emergency circumstances, we will disclose health information based on a determination using our professionaljudgement. We will also useour professional judgement and our experience with common practiceto make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
  • Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.
  • Marketing Health-Related Services:We will NOTuse or disclose your health information for marketing communications without your written authorization.
  • Required By Law:We may use or disclose your health information when we are required to do so by law.
  • Public Health and Public Benefit: e may use or disclose your health information to report abuse, neglect, or domestic violence; to report disease, injury, and vital statistics; to report certain information to the Food and Drug Administration (FDA); to alert someone who may be at risk of contracting or spreading a disease; for health oversight activities; for certain judicial and administrative proceedings; for certain law enforcement purposes; to avert a serious threat to health or safety; and to comply with worker’s compensation or similar programs.
  • Decedents: We may disclose information about a decedent as authorized or required by law.
  • National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials,health information required for lawful intelligence, counterintelligence, and other national security activities. We may also disclosethe protected health informationto correctional institutionsor law enforcement officials having lawful custody of an inmate or patient under certain circumstances.
  • Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, text messages, or letters).

QUESTIONS AND COMPLAINTS


If you want more information about our privacy practices or have questions or concerns, please contact us. If you feelthat:

  • We may have violated your rights
  • You disagree with a decision we made about access to your health information
  • You disagree with a decision we made in response to a request you made to amend or restrict the use or disclosure of your health information,or to have us communicate with you by alternative means or at alternative locations

You may file a complaintusing the contact information listed at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaintwith the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

CONTACT OFFICER


Dr. Damon B. Thompson


TELEPHONE


540.552.5433


FAX


540.552.2273


ADDRESS


250 South Main Street, Suite 212


Blacksburg, Virginia 24060



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